Cochrane Review of Homebirth Updated

Cochrane Review of Homebirth Updated

Observational studies of increasingly better quality and in different settings suggest that planned home birth in many places can be as safe as planned hospital birth and with less intervention and fewer complications. This is an update of a Cochrane review first published in 1998.

Review available online here:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000352.pub2/abstract

“The right to respect for private life includes the right to choose the circumstances of birth” said the European Court of Human Rights in Ternovzsky versus Hungary in 2010. Health authorities should consider establishing home birth services; this is the conclusion in a Cochrane analysis of planned hospital birth versus planned homebirth that was published today.

The authors Ole Olsen and Jette A Clausen find “the previous conclusions about “no statistical difference” in perinatal mortality (Olsen 1997a; Olsen 1998) seem to have been strengthened, and the results showing significantly lower morbidity rates related to home birth have become more convincing.

The review notes:

Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. However, there is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. Only two very small randomised trials have been performed. Only one trial (involving 11 women) contributed data to the review. They did not allow conclusions to be drawn except that women living in areas where they are not well informed about home birth may welcome ethically well-designed trials that would ensure an informed choice.

In summary it was found that:

Most pregnancies among healthy women are normal, and most births could take place without unnecessary medical intervention. However, it is not possible to predict with certainty that absolutely no complications will occur in the course of a birth. Thus, in many countries it is believed that the safest option for all women is to give birth at hospital. In a few countries it is believed that as long as the woman is followed during pregnancy and assisted by a midwife during birth, transfer between home and hospital, if needed, is uncomplicated. In these countries home birth is an integrated part of maternity care. It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. However, there is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. Only two very small randomised trials have been performed. Only one trial (involving 11 women) contributed data to the review. They did not allow conclusions to be drawn except that women living in areas where they are not well informed about home birth may welcome ethically well-designed trials that would ensure an informed choice.

Implications for practice
This review shows that there is no strong evidence to favour either planned hospital or planned home birth for selected, low-risk pregnant women. From an autonomy-based ethical perspective the only justification for practices that restrict a woman’s autonomy and her freedom of choice, would be clear evidence that these restrictive practices do more good than harm (Enkin 1995), as we stated in the previous version of this review (Olsen 1998).  A decade later, the European Court of Human Rights in Strasbourg handed down a judgment stating that “the right to respect for private life includes the right to choose the circumstances of birth”. Thus, no matter what the level of evidence is, European governments are not allowed to impose, e.g. “fines on midwives assisting at home births” as it “constitutes an interference in the exercise of the rights … of pregnant mothers” (Registrar 2010). On the other hand, the ethical concept of the fetus as a patient (Chervenak 1992) may lead some to state that “Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it” (Chervenak 2011) and that “In clinical practice it involves recommending … aggressive management (interventions such as fetal surveillance, tocolysis, Caesarean delivery)” (Chervenak 1992). In this ethical perspective recommendations about interventions are acceptable even when they are not supported by randomised controlled trial (RCT) data. The lack of strong evidence from RCTs and an autonomy-based ethical perspective lead to the conclusion that all countries should consider establishing home birth services with collaborative medical back up and offer low-risk pregnant women information about the available evidence and the possible choices.

Photo credit: Jane McCrae – http://www.janemccraephotography.com/