Women with low risk pregnancies should be able to choose where they give birth, concludes a study published on bmj.com today. Although it shows that first-time mums who opt for a home birth are at a higher risk of adverse outcomes, the overall risk is low in all birth settings.

The researchers say their results “support a policy of offering women with low risk pregnancies a choice of birth setting” and will enable women and their partners to have informed discussions with health professionals about planned place of birth.

The benefits and risks of birth in different settings have been widely debated in recent years, but there is a lack of good quality evidence comparing the risk of rare but serious perinatal adverse outcomes in these settings.

Perinatal refers to the period just before, during or shortly after birth.

So a team led by Professor Peter Brocklehurst from the University of Oxford for the Birthplace in England Collaborative Group set out to compare perinatal outcomes and interventions in labour by planned place of birth across all NHS trusts in England.

Planned place of birth included home, freestanding midwifery units, midwife-led units on a hospital site with obstetric services, and obstetric units.

Serious adverse outcomes included stillbirth after start of care in labour, early neonatal death, brain injury (encephalopathy), faeces in the lungs (meconium aspiration syndrome), and injuries to the upper arm or shoulder during birth.

A total of 64,538 single, full term infants born to women with low risk pregnancies were involved in the study. Factors, such as maternal age, ethnic group, body mass index and deprivation score were taken into account.

Overall, the rate of adverse outcomes was low in all birth settings (4.3 per 1,000 births) and there were no significant differences in the odds of an adverse outcome for any of the non-obstetric unit settings compared with obstetric units.

For women giving birth for the first time (nulliparous women), the risk of an adverse outcome was higher (9.3 per 1,000 births) for planned home births compared with obstetric units, but not for either midwifery unit settings. In contrast, for women who had given birth before (multiparous women), there were no significant differences in the rate of adverse outcomes between birth settings.

The results also show that interventions during labour, such as epidural, forceps delivery or caesarean section, were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were also much higher (up to 45%) for nulliparous women than for multiparous women (up to 13%).

“These results will enable women and their partners to have informed discussions with health professionals in relation to clinical outcomes and planned place of birth,” say the authors. “For policy makers, the results are important to inform decisions about service provision and commissioning.”

They add that a cost effectiveness analysis of the different birth settings is currently being carried out, and they suggest that further research on this issue is needed, particularly into the effect of staffing and service configuration on outcomes, and more detailed analysis of transfers from non-obstetric settings.

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Emma Dickinson
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BMJ-British Medical Journal