Objective To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies.
Design Prospective cohort study.
Setting England: all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units.
Participants 64 538 eligible women with a singleton, term (>= 37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded.
Main outcome measure A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units).
Results There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. Interventions during labour were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%).
Conclusions The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.
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Comment by AIMS:
The debate about the safety of hospitals and the risks of home birth has been much debated since the publication of a long-awaited large prospective cohort study of 64 538 eligible women with a singleton, term (>= 37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded. (Brocklehurst, P 2011).
This research (known as the BirthPlace Study) shows that low-risk women are safer when they give birth outside an obstetric unit, in alongside or free-standing midwifery units, or at home. Women have fewer caesarean, ventouse deliveries, episiotomies, less blood loss, and other benefits. These outcomes will have benefits that this study was unable consider, such as better breastfeeding rates and safer future births. The study showed no difference for second or subsequent babies by place of birth, nor for first time mothers between midwifery units and consultant units. However, a small statistically significant increased risk was shown for babies of first time mothers born at home. However, in order to gain finance for the study the researchers will have required an outcome measure that had a chance of showing a statistically significant difference between the groups and baby deaths would have been too few to do this. So they combined: stillbirth after the start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, and fractured clavicle. So, what can be said is that women are safer having their babies at home or in midwifery units, but there is no evidence about whether there is an increased risk of stillbirth or neonatal death for the baby because the incidence of this is so small we would need a much bigger study than the 65,000 women in this study in order to be able to detect a difference. The attention of the medical profession in every country in Europe should be drawn to this study.
Les femmes qui souhaitent accoucher dans une unité de sage-femme, et les multipares qui souhaitent accoucher à domicile subissent moins d’interventions ue celles qui souhaitent accoucher dans une unité obstétricale, sans impact sur les résultats périnataux.
Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes.
Mulheres que desejam dar à luz em uma unidade de obstetrícia, e mulheres multíparas que desejam dar à luz em casa, recebem menos intervenções do que aquelas que desejam dar à luz em uma unidade obstétrica.
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