Pregnant with controversy: Nursing Review Article

[Visitor6]

As a member of the Royal College of Nursing Australia I thought this might be a worthy article to reprint for you all whatever your view.

Pregnant with controversy

Nursing Review. Royal College Of Nursing Australia Februrary 2010

Nursing Review - Pregnant with controversy

A new study on differences in outcomes of home and hospital births has reignited the home birth debate, but according to the study’s author its main message has been lost.

Instead, both sides of the argument – home birth and doctor groups – have turned to sensationalism, said Professor Marc Keirse.

“Everyone has gone into a frenzy. Home birth groups are saying the study is flawed while doctors are saying babies born at home will die,” he said.

Keirse, professor of obstetrics and gynaecology at Flinders University, and his co-authors compared outcomes of home births, occurring at home or in hospital, to planned hospital births in South Australia between 1991 and 2006.

The study found the perinatal mortality rates of home and hospital births to be similar. But it also found babies born at home were seven times more likely to die from complications and 27 times more likely to suffer asphyxiation during labour.

Following its publication in the latest edition of the Medical Journal of Australia, doctors claimed the study proved home births were unsafe, with news headlines supporting this appearing across the country.

“The AMA does not support home birth because of the safety concerns for mother and baby, and this latest independent study backs our concerns,” Dr Andrew Pesce, AMA president, said.

At the same time, home birth groups questioned the findings, claiming the study was “fundamentally flawed”.

Both are guilty of giving an incorrect assessment of the findings, said Keirse, who is frustrated that the important points of the study are, as a result, being overlooked.

Firstly, he said, the findings of a sevenfold higher risk of intrapartum death for home births needed to be looked at in context. This included the small numbers – 287,192 planned hospital births and 1141 planned home births. Of the planned home births 30 per cent ended up occurring in hospitals. “Although our study has shown few adverse outcomes from planned home births in SA, small numbers with large confidence intervals limit interpretation of these data,” the study states.

Nine deaths occurred among the home birth group, but seven of those occurred in hospital after the mother had changed her mind against a homebirth or needed transferring.

Of the two deaths that occurred in the home one baby had congenital abnormalities. The study states that this was suspected on ultrasound but the parents declined further investigation with a decision made to continue with a home birth.

The second was a fresh stillbirth from a water birth. Although birth under water was thought not to have contributed to the death, closer monitoring during labour may have changed the outcome, the study stated.

Of the seven deaths that occurred within the home birth group at hospital, the authors said they could not differentiate all planned home births according to whether transfer to hospital had occurred before or during labor.

So angry at the media’s “irresponsible and misleading” reporting of the study is the Australian College of Midwives that they have approached the ABC television program Media Watch.

“All the media has done is to be led by the AMA, without looking at all the data included in the study,” Hannah Dahlen, vice president of the Australian College of Midwives, said.

“It’s also disappointing that the positive benefits of home birth reported in the study have not made it into many articles. There was significantly less intervention in the home birth group with 9 per cent of women who planned a home birth having a caesarean, compared to 27 per cent in the hospital group.”

Recommendations made in the study to improve home birth outcomes – such as better adherence to risk assessment, timely transfer to hospital when needed and closer fetal surveillance – have also been under-reported, said Dahlen.

“Home birth will not go away. It has, does and will exist in every country on earth. So we have two options – burry our heads in the sand and hope it goes away, it won’t, or put in place responsive, evidence based systems of care – we haven’t.”

Keirse said the study showed that the whole maternity system needed to be looked at and the debate of whether home birth should or shouldn’t be an option for women was hindering this.

“It’s a women’s right to choose where she gives birth. That is a basic fact. People shouldn’t be having an opinion on this. What the focus needs to be on, and what it should only be on, is how we make the practice safe,” he said.

“The last sentence in the study says it all: Respecting their choices and achieving the best outcome for all concerned is likely to remain a challenge that will require more light and less heat that it has received thus far.”

A closer look

Associate Professor Hannah Dahlen and Professor Caroline Homer, from University of Technology Sydney, take a critical look at the study and the way its findings have been portrayed.

• One of the problems is that the planned home birth group includes women who planned home birth when booking in for care but then developed risk factors and had their babies in hospital. There are probably only two women whose babies died; who started labour at home planning a home birth and one of these was a twin pregnancy (high risk). This latter woman persisted in having a homebirth due to “unsatisfactory hospital experiences”. The others had all transferred before the onset of labour. The authors admit they “could not differentiate all planned homebirths according to whether transfer to hospital had occurred before or during labour”. So for low risk women who started labour at home the risk was very low – one death in 16 years

• This was not a low risk population of women – there was a high rate of post-term pregnancy (3.8 per cent in the planned homebirth group vs 1.2 per cent in the planned hospital birth group); twins (five sets of twins); and 8.8 per cent of women had a previous caesarean section.

• The numbers of perinatal deaths in the homebirth group over 16 years were small (nine deaths).

• There were two perinatal deaths that actually occurred at home. One baby had lethal congenital abnormalities (this was known before labour and a decision made for the baby to be born at home). The second death at home was after a water birth which was not found to be the cause of death but a review identified that increased monitoring may have identified the baby was in distress.

• One perinatal death occurred in hospital after a transfer after the birth of the first twin. The first twin was born at home and second twin was born in hospital after a delay in transfer and subsequently died.

• There were six perinatal deaths in the planned home birth group where the baby was born in hospital. Presumably these women were transferred to hospital during the antenatal period as risk factors developed. Transferring to hospital if or when risk factors develop during pregnancy is appropriate practice.

• Three of the deaths were thought to be potentially preventable and related to the model of care. These were the baby born after the water birth at home; the second twin who was born after an intrapartum transfer and the baby born after being very postdates. Therefore, there were three deaths in 16 years – two of which had risk factors present. That means that there was only one death where there were no risk factors in the 16 year period.

• The numbers of planned homebirths are small (n=1141) (gave birth at home n=792; in hospital n=349). You cannot look at the rare outcome of intrapartum death in such a small sample as the wide confidence intervals demonstrate (95 per cent CI 1.53-35.87) (there is 1 intrapartum death at home and 1 in hospital). It is difficult to examine intrapartum asphyxia with any certainty due to the very small numbers and again the very wide confidence intervals show this (one at home and two in hospital). You would need more than 10,000 births at home to show clinical relevance and have some confidence in the statistical significance in relation to perinatal mortality rates. The authors acknowledge this in the paper and present their data with caution in the paper.

• The facts are there was no difference in perinatal mortality (stillbirths, and neonatal deaths within 28 days of birth) between home and hospital (7.9 vs 8.2 per 1000 births). For those actually born at home the perinatal mortality rate is 2.5 per 1000 births, which is comparatively low.

• The paper highlights that the system must be so terrible for some women that they would choose to give birth outside of it than in it, even with risk factors. This is an indictment on the current maternity system in Australia – that needs fixing – removing homebirth won’t do this.

[Schmickers]

An interesting article, SB.

It is unfortunate for Keirse et. al. that they chose to word their study in the way that they did - drawing assertions in the article that were not supported by the data. If the data need to be looked at in context, and the small confidence intervals limit the usefulness of the data (which is true, they do), then why make the declarations that they do? That intrapartum mortality is seven times higher, that birth asphyxia is 27 times higher? Why not simply tell the truth - that they were unsuccesful in recruiting enough valid homebirths to the study to draw meaningful conclusions? Why claim that closer monitoring might have changed the outcome of a stillbirth when there is no such evidence to support that claim?

It is certainly true that the AMA have sensationalised the study in a vain attempt to use it to support their unjustified opposition to homebirth, and I do feel for the authors that the message they wished to convey is being missed. But this is as much their fault as the AMAs. The way the study was conducted was fundamentally flawed. It failed at the very first hurdle - accurately classifying those women who had a homebirth - and therefore, any results from the study are simply invalid. This is the fault of no one but the authors.

[AngelsMum]

He says this:

Home birth groups are saying the study is flawed while doctors are saying babies born at home will die,” he said.

then this:

the findings of a sevenfold higher risk of intrapartum death for home births needed to be looked at in context.

Nine deaths occurred among the home birth group, but seven of those occurred in hospital after the mother had changed her mind against a homebirth or needed transferring.

“It’s also disappointing that the positive benefits of home birth reported in the study have not made it into many articles. There was significantly less intervention in the home birth group with 9 per cent of women who planned a home birth having a caesarean, compared to 27 per cent in the hospital group.”

And from the Professors' critical look

You would need more than 10,000 births at home to show clinical relevance and have some confidence in the statistical significance in relation to perinatal mortality rates.

Isn't this what the home birth groups are trying to point out?