Objective - To assess procedures and outcomes in
deliveries planned at home versus those planned in hospital among women
choosing the place of delivery.
Design - Follow up study of matched pairs.
Setting - Antenatal clinics and reference hospitals in
Zurich between 1989 and 1992.
Subjects - 489 women opting for home delivery and 385
opting for hospital delivery; the women comprised all those attending
members of the study team for antenatal care and those attending the
reference hospital for antenatal care who could be matched with the
women planning home confinement.
Main outcome measures - Need for medication and
incidence of interventions during delivery (caesarean section, forceps,
vacuum extraction, episiotomy), duration of labour, occurrence of
severe perineal lesions, maternal blood loss, and perinatal morbidity
and death.
Results - All women were followed up from their first
antenatal visit till three months after delivery. Referrals during
pregnancy (n=37) and labour (70), changes of mind (15 home to
hospital, eight hospital to home), and 17 miscarriages resulted in 369
births occurring at home and 486 in hospital. During delivery the home
birth group needed significantly less medication and fewer
interventions whereas no differences were found in durations of labour,
occurrence of severe perineal lesions, and maternal blood loss.
Perinatal death was recorded in one planned hospital delivery and one
planned home delivery (overall perinatal mortality 2.3/1000). There was
no difference between home and hospital delivered babies in birth
weight, gestational age, or clinical condition. Apgar scores were
slightly higher and umbilical cord pH lower in home births, but these
differences may have been due to differences in clamping and the time
of transportation.
Conclusion - Healthy low risk women who wish to
deliver at home have no increased risk either to themselves or to their
babies.
Introduction
Since the 1940s hospital has been considered to be the safest
place for a woman to give birth. Probably partially owing to optimal
standards of hygiene in hospital and the availability of equipment
perinatal and maternal death rates in Switzerland are among the lowest
in the world (8.0/1000 and 0.02/1000, respectively (1990 data)).
Questions about possibly increased risks to healthy mothers and their
children in hospital were first raised in the
1980s.(1)
In 1990, 99% of all deliveries in Switzerland took place in
hospital.(2) As delivery has become safer, however,
so there has been growing desire among women to move away from
interventions and hospitals to more "natural" childbirth. A team of
general practitioners and midwives in the canton of Zurich (population
1.1 million) responded to this wish by offering the possibility of home
delivery to those who requested it. The Swiss health care system is
private for all outpatient care, so every woman may choose where to
deliver. Fees are covered by health insurance, to which everybody
subscribes.
We report a quality control study of hospital versus home delivery
conducted by the team, which was organised for the purpose. As only few
studies had systematically compared home and hospital
deliveries(3-6) the team studied matched pairs. For
ethical and practical reasons a randomised trial was not
possible(7)
Methods
This was a prospective cohort study with matched pairs. Doctors and
midwives of the study team recruited all pregnant women at their first
antenatal visit with one of them between March 1989 and March 1991 or
when at a subsequent visit they first decided to have a home delivery.
The entry criterion for each category was the intention to deliver at
home or in hospital (recorded during the first antenatal visit or when
the decision was taken) and an outcome criterion the place where
delivery actually occurred. The team had no formal policy on criteria
for accepting women for home delivery. Hence reasons for hospital
referral were also recorded as an outcome in the home delivery group.
Planned hospital deliveries were included only if they were to take
place at one of the reference hospitals in the study. These were
restricted in order to make comparison and access to data easier. It
soon became apparent that not enough women wishing to deliver in
hospital could be recruited, and private gynaecologists and outpatient
departments of the larger obstetric clinics in Zurich were asked to
participate. Most women who attended those agencies for antenatal care,
however, were excluded because of medical history or nationality.
Ultimately matching was possible mainly for healthy Swiss nationals
with good educational background, as these were the group who selected
themselves for home delivery. Complete data were collected on all
selected women who opted for hospital delivery, though because of
strict matching criteria (see box) a matching partner could be found
for only about half of women potentially delivering at
home.
| Matching criteria for whole study population
|
| Age <16, 16-19, 20-29, 30-34, >34 years
Parity 1, 2-4, >4
Gynaecological and obstetric history (none or 24 categories
which could be combined)
Medical history (none or 12 categories)
Partner situation (living with a partner, or living with other
people, or living alone)
Social class (five categories described by
Beer(8))
Nationality |
Recruitment
Sample size calculations suggested that it would be impossible to find
enough home deliveries in order to show differences in perinatal
mortality and other rare outcomes. The team therefore recruited all
women delivering at home in the canton in the two years, an estimated
sample size of 500 allowing comparison of more frequent or qualitative
outcomes - for example, caesarean section, Apgar scores, and birth
weight.
A total of 951 pregnant women were recruited - 493 who wished to deliver
at home and 458 who requested hospital delivery and satisfied criteria
for serving as a matching candidate. Women who opted for home delivery
were recruited between March 1989 and March 1991 and those requesting
hospital delivery recruited between March 1989 and their expected date
of delivery up to 31 March 1992.
In 1990 the Swiss Association of Midwives recorded 220 planned
and 201 actual home deliveries in the canton of Zurich (annual report
1990, Jahresbericht des Schweizerischen Hebammenverbandes Sektion
Zurich und Umgebung). The study team recorded 232 planned and 203
actual home deliveries. Even with the exclusion of women who for social
reasons changed their minds during pregnancy the team still recorded
more deliveries. It therefore seems likely that all home deliveries in
Zurich during the study period were included in the study.
Data collection
Members of the study team recorded data about every antenatal visit on
specially designed forms. These were later coded and entered into
computerised files. In addition, a delivery form was completed by the
midwives. The hospitals could not be persuaded to use these forms, and
data were therefore coded in the same way according to preset criteria.
Newborn infants were examined immediately after birth by the general
practitioner or obstetrician and on about the third day by specially
trained paediatricians. The findings of this second examination were
recorded following a scheme developed by the Swiss Neonatology
Group.(9) This could not be done for hospital
deliveries, but a similar form was used by all the hospitals.
In addition, the mothers completed three questionnaires. A first
questionnaire, during pregnancy, asked about attitudes to childbearing
and delivery; a second questionnaire, completed at the same time,
sought medical and social histories. Three months after delivery
a third questionnaire was mailed to the mothers. This was based on a
draft for an English national perinatal survey (personal communication)
and asked about the experience of birth and the puerperium.
Written consent was obtained from all women. Confidential treatment of
data was assured.
Processing and analysing data
Hospital records and records of home deliveries were coded by specially
trained personnel not associated with the study and data entered in an
spss file. Data were analysed separately for the different
stages of the study and also separately for matched pairs and all
women. A common database was then formed for all stages and transferred
to the mainframe computer at the Amt f\)r Informatik in Basle. Further
analyses were by spss and sas on a mainframe
computer.
This paper reports findings from matched and unmatched comparisons
without adjustment for differences in social class and so on in the
unmatched sample. Statistical significance of differences in means of
quantitative variables between cases and controls was assessed by the
one sample t test whereas McNemar's test was used to compare
the frequency of binary characteristics between matched samples. In
unmatched analyses the two sample z test and the x(2) test
or Fisher's exact test were used instead. In matched analyses odds
ratios were estimated by the ratio of discordant
pairs.(10)
Study population
Of the 951 women recruited, 70 who had planned their deliveries in
hospital were excluded for being unmatchable owing to nationality
(n=22) or medical history (5) or because their delivery was planned
in a setting not conforming with the study criteria (43). One woman who
had planned a home delivery was excluded for the same reason. Six women
(three planned home and three planned hospital births) moved away
during pregnancy and were lost to follow up. Thus 489 planned home
deliveries and 385 planned hospital deliveries remained in the study. A
total of 214 matched pairs were formed (49% of women in the study).
Results
Study groups
Tables 1 and 2 show the socioeconomic and health characteristics of the
study groups(1) and, when available (table 1),
comparable data for the rest of the childbearing Swiss population in
1991. In the matched pairs analysis women in the home births group
weighed less than the hospital group.
| Table 1 - Matching criteria for whole study group.
Except where stated otherwise figures are numbers (percentages) of
women |
| Planned home (n = 489*) | Planned hospital (n = 385*) |
P value | Total study group (n = 874* ) | Average for rest of
childbearing Swiss population (%) |
| Mean age at conception
(years) (SD) | 29.2 (4.3) | 29.2
(4.6) | 0.95 | 29.2 (4.4) |
|
| Mean age
at delivery (years) |
|
|
| 30.0 | 28.9 |
| Parity: |
| 1st Child | 201
(41.1**) | 182 (47.3**) |
| 383 (43.8**) | 44.9*** |
| 2nd Child | 175 (35.8**) | 143 (37.1**) | 0.02 | 318
(36.4**) | 36.7*** |
| 3rd Child or more | 113 (23.1**) | 60
(15.6**) |
| 173 (19.8**) | 18.4*** |
| Partner situation: |
| Living with partner | 452
(92.4) | 346 (89.9) |
| 798 (91.3) |
|
| Living with
group | 15 (3.1) | 4 (1.0) | 0.004 | 19 (2.2) |
|
| Living alone | 22 (4.5) | 35 (9.1) |
| 57 (6.5) |
|
| Marital status: |
| Married | 314 (71.4) | 219
(82.0) | 0.002 | 533 (75.4) | 93.9 |
| Not married | 126
(28.6) | 48 (18.0) |
| 174 (24.6) | 6.1 |
| Nationality: |
| Swiss | 453 (92.6) | 360
(93.5) | 0.69 | 813 (93.0) | 80.3 |
| Other | 36
(7.4) | 25 (6.5) |
| 61 (7.0) | 19.7 |
| Social
class: |
| Self employed | 341
(69.7) | 184 (47.8) |
| 525 (60.1) |
|
| Skilled | 122
(25.0) | 162 (42.1) | <0.001 | 284 (32.5) |
|
| Unskilled, agriculture, missing | 26 (5.3) | 39 (10.1) |
| 65
(7.4) |
|
| * Except for marital status, where n = 440 (planned home),
n = 267 (planned hospital), and n = 707 (total).
**Rank of children of these women.
***Rank of children from same marriage, therefore not completely
comparable. |
In the whole study population
there were other differences between women planning a home birth and
women planning a hospital birth. Women in the home births group were
more likely to live with a partner and to be employed before pregnancy.
They were taller but weighed less than the hospital group whereas no
differences were shown in age, profession, or
nationality.
Attitude
The attitude questionnaire confirmed that women booking for home
confinement had greater self determination than the controls. They
wanted to influence and determine the birth themselves and preferred to
rely on intuition rather than on the advice of professional
carers. They also required more intimacy in the birth setting than
women planning a hospital delivery. Women in the home births group were
noticeably less anxious about delivery and had more confidence in their
bodies than women in the hospital group.
Outcomes of pregnancy and actual place of delivery
Of the 874 women in the study, 17 miscarried (fig 1). Seven
miscarriages were recorded in the matched pairs analysis, two in the
planned home deliveries group and five in the planned hospital
deliveries group. For the analysis of birth outcome these miscarriages
reduced the number of matched pairs available to 207 (414 women). Among
the remaining 483 women in the planned home delivery group, 37 (7.7%)
were referred to hospital during pregnancy and 15 (3.1%) changed their
minds and wished to give birth in hospital. Conversely, eight (2.1%)
of the 374 women in the planned hospital delivery group changed to
wishing to deliver at home. Among these women, four were referred to
hospital during delivery. After the onset of labour 70 (15.9%) of the
remaining 439 women had to be transferred to hospital. This proportion
was considerably higher in primiparous women (25%). Thus 369
deliveries actually occurred at home and 486 in hospital. Two women who
wished to deliver in hospital gave birth unattended, one at home and
one in the taxi. Both women went to hospital for postnatal
care.(11)
Obstetric complications
There was no difference between the home birth and hospital birth
groups in the incidence of breech presentation, twins, pre-eclampsia,
premature rupture of the membranes, premature birth, vaginal bleeding,
or post-term delivery (table 3). There were, however, more premature
births in the planned hospital deliveries group (table 3). There were
no consistent differences in the durations of labour between the groups
(table 4). Not one maternal death occurred during the study.
Of the 70 women booked for home delivery who were transferred to
hospital after the onset of labour, 20 showed signs of fetal distress
(abnormal fetal heart rate or green amniotic fluid, or both), 16
underwent caesarean section, and 14 had a vaginal operative delivery.
During delivery women in the home births group needed significantly
fewer inductions of labour, less analgesia, and less medication to
induce or support labour. They also had fewer caesarean operations and
less application of forceps or vacuum extraction. Episiotomy was also
less frequent in the planned home births group; on the other hand,
severe perineal lesions were not more frequent in this group (table 5).
Women at home usually delivered sitting, on knees and elbows, or
standing; women in hospital usually delivered horizontally. Blood loss
in all vaginal deliveries was the same in both groups (median 300
ml).(12)
Neonatal outcome
Perinatal death was recorded in one planned home delivery (a stillbirth
discovered at term before the onset of labour with no apparent
abnormality in the fetus or placenta) and one planned hospital delivery
(the infant died on the second day with multiple malformations,
including hypoplasia of the left ventricle). These cases correspond to
a perinatal death rate of 2.3/1000 (perinatal death rate in Zurich
(1990 data) 7.9/1000).
Morbidity - Comparing birth weights and gestational ages
of infants in the planned home and hospital delivery groups (table 6)
showed no differences either in mean values or in numbers of cases with
weights or ages outside the normal range. The mean Apgar score at one
minute was the same in both groups, but at five and 10 minutes babies
in the planned home delivery group had higher scores. On the other
hand, the mean pH in umbilical arterial and venous blood was lower in
the home births group, which also had more infants with arterial pH
under 7.15. Detailed examination by a neutral paediatrician between the
2nd and 6th days of life showed no differences between home and
hospital born
infants.(13)
Mothers' experience
We record only some of the most important findings of the questionnaire
sent to women three months after delivery. Seventy per cent of women in
the home births group and 48% of women in the hospital births group
ticked "the birth was my own achievement" (P<0.05). Home births
showed more constancy in relation to care professionals, who mostly
were known to the women before delivery and seldom changed, staying
even during prolonged labour. A clear difference emerged in the
subgroup of women whose labour lasted more than 12 hours. Women
delivering at home were cared for more patiently and encouraged more to
deliver spontaneously; even when referred to hospital these women's
experience was not worse than that of women in hospital who had a
vaginal operative delivery.
Movement and massage were the most frequent devices used to combat pain
in both groups. Ninety per cent of women delivering at home reported
that they could always move freely and 59% that they could choose
their birth position; 57% of women in hospital reported that they
could move freely and 35% that they could choose their birth position.
In 64% of home births and 62% of hospital births the father helped to
care for the baby. Ninety four per cent of mothers delivered at home
and 84% of mothers delivered in hospital held the baby immediately
after birth; 86% and 73% of mothers, respectively, nursed the baby
within the first hour of life.
Discussion
In Switzerland women wishing to deliver at home are a small minority.
As this study confirms, they do not represent the childbearing Swiss
population but are a self selected, low risk group with good health.
Studying the outcome of home deliveries is important for quality
control, but findings should be interpreted with caution. The number of
participants was too small to detect differences either in maternal or
perinatal mortality between the groups or in rare birth
complications - for example, not one case of umbilical cord prolapse or
abruptio placentae occurred. However, the low perinatal death rate was
commensurate with the low risk status of the study population.
Characteristics of women who wish for home delivery
Overall the women recruited for this study had a higher educational
level and included more Swiss nationals than the average childbearing
population in Switzerland.(14)(15) The
women were also older and included a higher proportion living with a
partner. No difference in parity could be shown between the study
population and other pregnant Swiss women (birth certificates record
only the number of children from the same marriage, not parity).
Women who planned their deliveries at home and in hospital differed in
their attitudes to health, pregnancy, responsibility, and independence.
Usually it takes a certain tenacity for a woman to realise a home birth
in a health care system in which this is considered irresponsible. The
eight women who changed their minds during pregnancy and wanted a home
birth rather than hospital delivery (who might therefore have been less
convinced than other women) had a high rate (50%) of referral during
labour.
Main results
A lower rate of caesarean section and vaginal operative delivery as
well as restricted use of agents to induce or stimulate labour were
associated with a more expectative management of premature rupture of
the membranes and post-term pregnancy in the home births group.
Stricter indications for episiotomy were used in home deliveries. There
was no evidence that the more liberal use of episiotomy in hospitals
prevented severe perineal lesions.
The lower rate of interventions in home births meant a lower risk of
subsequent complications for the mother. This advantage was not
outweighed by a worse neonatal outcome. However, infants in the planned
home delivery group seemed mildly more stressed immediately after birth
(lower umbilical cord pH), though they recovered better than babies in
the planned hospital delivery group (higher Apgar scores at five and 10
minutes). Differences in umbilical cord pH may have been due to
differences in clamping and the time of transportation. In home
deliveries the umbilical cord was mostly clamped late (1-20 minutes
(mean 5) after delivery) and transportation to a measuring instrument
took on average 83 minutes. Each factor can lower the
pH.(16-20)
Problem of matching
Under the circumstances of antenatal care in Switzerland randomisation
of women wishing for home delivery was not considered feasible, so
women were matched at the first consultation. In a country where over
99% of deliveries take place in hospital this should have been easy,
and strict matching criteria were therefore defined. This led to
problems: any women with a gynaecological, obstetric, or medical
history was difficult to match; the matched pairs therefore included
the healthiest women and more primiparous women than in the total
group. Socioeconomic status also differed between home and hospital
delivered women in the total group: results are presented for each
separately. The matched pairs showed more precise odds ratios but wider
confidence intervals.
The biggest difference in personal characteristics between the home
delivery and hospital delivery groups was in their attitudes to
delivery and confinement. These differences were statistically
significant but not of a magnitude which would explain the large
differences in management of delivery between the groups.
Conclusion
In a setting in which pregnant women can choose the place of delivery
and attention at home is guaranteed, a referral system is available and
adequate, and hospitals respect the patient's original decision when
she arrives there, home delivery has advantages over hospital delivery:
home delivery results in fewer interventions and more comfort for the
mother.
This study does not have sufficient power to exclude differences
in rare events. The probability of these events concerns both
sides - for example, the rare complications of interventions in hospital
as well as unmanageable bleeding at home. However, most indicators
suggest that home delivery does not pose a higher risk than hospital
delivery and that it reduces some of the additional risks of
interventions. This study has improved collaboration between hospitals
and the home delivery teams, thus possibly leading to lower risk for
all women concerned. Many questions remain open and need to be studied
in places with a higher proportion of home deliveries.
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Institute for Social and
Preventive Medicine of the University of Basle,
CH-4051 Basle,
Switzerland
Ursula Ackermann-Liebrich, professor and
head
Kathrin Gunter-Witt, research fellow
Isabelle Kunz, research fellow
Maja Zullig,
research fellow
Christian Schindler,
statistician
Zurich Canton,
Switzerland
Thomas Voegeli, general practitioner
Margrit
Maurer, midwife
Zurich Study Team
Correspondence to: Professor
Ackermann-Liebrich.
Members of the study team were: general
practitioners Th Voegeli, E Ashkenazi, J Ashkenazi, U Bachmann, D
Baumann, N Egli, P Frey, U Gehrig, U Glenck, P Hofmann, M Huber, C
Jordi, C Landerer, P Lattmann, B Maggi, R Niehus, B Oertli, D Rahle,
J Reichel, T Walser, and D Winizki and midwives M Maurer, C America, I
Barlocher, H Burki, L Daemen, E Geier, S Gloor, O Hagler, R
Herzog, B Landheer, M J Meister, E Schibli, and E Zingg.
We thank the Institute for Social and Preventive Medicine of the
University of Zurich (head, Professor Dr F Gutzwiller) for hosting the
study and for informatics and statistical support (Dr A Tschopp),
Professor Renata Huch (university department of perinatal physiology,
Zurich) for the pH measurements and advice, Dr Ursula Morf for
developing and analysing the psychological instruments, Lilian Thur for
laborious and conscientious collection of data during the whole study
and centrally coordinating all information, Dr R Zelesniak for
improving collaboration in hospital data collection, Dr Alison
MacFarlane for critically reviewing the manuscript, and all the mothers
who participated for consent and for replying to the questionnaires.
Funding: Swiss National Science Foundation (grant No
3.807.0.87).
Conflict of interest: None.
(Accepted 24 September 1996)
