Objectives To test the hypothesis that low risk women at the onset of labour with planned home birth have a higher rate of severe acute maternal morbidity than women with planned hospital birth, and to compare the rate of postpartum haemorrhage and manual removal of placenta.Design Cohort study using a linked dataset.Setting Information on all cases of severe acute maternal morbidity in the Netherlands collected by the national study into ethnic determinants of maternal morbidity in the netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, merged with data from the Netherlands perinatal register of all births occurring during the same period.Participants 146 752 low risk women in primary care at the onset of labour. Main outcome measuresSevere acute maternal morbidity (admission to an intensive care unit, eclampsia, blood transfusion of four or more packed cells, and other serious events), postpartum haemorrhage, and manual removal of placenta.Results Overall, 92 333 (62.9%) women had a planned home birth and 54 419 (37.1%) a planned hospital birth. The rate of severe acute maternal morbidity among planned primary care births was 2.0 per 1000 births. For nulliparous women the rate for planned home versus planned hospital birth was 2.3 versus 3.1 per 1000 births (adjusted odds ratio 0.77, 95% confidence interval 0.56 to 1.06), relative risk reduction 25.7% (95% confidence interval −0.1% to 53.5%), the rate of postpartum haemorrhage was 43.1 versus 43.3 (0.92, 0.85 to 1.00 and 0.5%, −6.8% to 7.9%), and the rate of manual removal of placenta was 29.0 versus 29.8 (0.91, 0.83 to 1.00 and 2.8%, −6.1% to 11.8%). For parous women the rate of severe acute maternal morbidity for planned home versus planned hospital birth was 1.0 versus 2.3 per 1000 births (0.43, 0.29 to 0.63 and 58.3%, 33.2% to 87.5%), the rate of postpartum haemorrhage was 19.6 versus 37.6 (0.50, 0.46 to 0.55 and 47.9%, 41.2% to 54.7%), and the rate of manual removal of placenta was 8. 5 versus 19.6 (0.41, 0.36 to 0.47 and 56.9%, 47.9% to 66.3%).Conclusions Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system.

Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

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Background Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non‐steroidal anti‐inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods A prospective multicentre cohort study was delivered by an international, student‐ and trainee‐led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre‐specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results A total of 4164 patients were included, with a median age of 68 (i.q.r. 57–75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1–3, of whom 1061 (92·0 per cent) received non‐selective cyclo‐oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001). Conclusion NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

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