Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study

Abstract

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.

Maternal Results From Planned Home Births Assisted by Nurses From the Hanami Team in the South of Brazil, 2002-2012

“…The majority of the findings are similar to those already published in studies undertaken in Brazil and other, developed, countries. 4,6,10,12-13, [23][24][25][26] One of the limitations for discussing the present study's findings is the meager publication of quantitative Brazilian data regarding assistance at home so as to compare the results obtained. [10][11]19 In relation to the sociodemographic characteristics, the age range of the majority of the women was below that found in the international studies (between 30 and 34 years old) [26][27][28][29][30] and in another Brazilian study (30-35 years old).…”

“…International studies have also demonstrated that it is women with higher socioeconomic status who opt for this place to give birth. [3][4]24,29,32 In Brazil, only a small number of home births are attended through the Unified Health System (SUS), being undertaken by the team from the Sofia Feldman Hospital. 33 Other countries support this type of attendance as an integral part of their Health Systems, as is the case with Holland, 4 Australia, 26 Canada, 5 New Zealand 30 and the United Kingdom.…”

“…[3][4]6,12,[23][24][26][27][28][29][30]32,34 However, one can observe an increase in the number of multiparous women who opted for home birth (Figure 2), which may result from the satisfaction with the previous experience of birth at home, and from the dissatisfaction of women who gave birth for the first time in hospital.…”

“…Generally speaking, the studies do not present this data. Some indicate the rate of manual removal of the placenta as being between 1.0% and 1.6%, 6,12,24 making it necessary to investigate this issue in the home context.…”

Shared Decision-Making Regarding Place of Birth–Mission Impossible or Mission Accomplished?

“…When midwives understand the woman's decision making process regarding place of birth and how to support this process, they are better equipped to facilitate women's decision making in their care and it will allow midwives to move away from a 'home versus hospital birth' debate. 22 In a maternity care system where home-birth is an integrated part of maternity services and where midwives are the main care providers during pregnancy; who aim to maintain the provision of offering homebirth to healthy women, 2,10 it is important to fully understand the features of women's decision making about place of birth 2,10 in order to facilitate this process.…”