Letters

Choosing between home and hospital delivery

Home birth in Britain can be safe

There is no evidence that hospital is the safest place to give birth

Risk of home birth in Britain cannot be compared with data from other countries

Author's reply

Home birth in Britain can be safe

EDITORDrife's assertion that hospital birth is three times as safe as planned home birth is misleading.¹ Since the study groups were dissimilar it is about as helpful as saying that a man and a dog have an average of three legs. He is also wrong to say that "no recent audit of the safety of home delivery in Britain is available." Just such an audit has been running here for 18 years.² There has been no intrapartum death and only one neonatal (0-27 day) death in the past 15 years among the estimated 3400 mothers (0.6%) who were booked for home birth when labour started. The comparable figure for all such births in this region for these years (1984-98), after lethal malformation and babies weighing less than 2.5 kg are excluded, is 1:921 (587/540 830). That home birth has become statistically "safer" than hospital birth is not, of course, unexpected, as high risk mothers seldom press for home delivery.³

National figures also exist. The comparable figure for all booked home births in 1994-5 nationally, as established by the Confidential Enquiry into Stillbirth and Death in Infancy, was 1:1113 births (22/24 484), although this denominator includes unplanned home birth and excludes transfers in labour.⁴ This is similar to the rate in non-malformed births of 2.5 kg in these two years (1143/1 224 856, or 1:1072 births). The National Birthday Trust study, which did collect accurate denominator data during 1994, encountered two stillbirths and three neonatal deaths among the 4665 mothers still booked for a home birth at 37 weeks' gestation (1:933 births).⁵

We agree that women should be able to choose between home and hospital delivery. They also need accurate and balanced information. Unfortunately, that is not what Drife gave those who read his letter to the Times of 20 May or the letter he sent the BMJ. He did not compare like with like, and he merged groups who should be advised differently. Most women can be told that, as long as they continue to accept professional advice, they are as safe delivering at home as in hospital. For others with a twin, breech, or post-term pregnancy the increased risk of home birth is probably even greater than Drife's figure suggests.

The current polarised argument is futile. Doctors and midwives would be better employed collecting the information needed for women to be given more individually specific advice. Women would then be more likely to believe what they are told during pregnancy and, even more importantly, during labour.

Gavin Young, general practitioner. 
youngjckvg{at}compuserve.com

Edmund Hey, retired paediatrician. 
Regional Perinatal Mortality Survey Coordinating Group, Maternity Survey Office, Newcastle upon Tyne NE2 4AA

There is no evidence that hospital is the safest place to give birth

EDITORDrife's conclusions, arrived at after relating data from the confidential enquiry into stillbirths and deaths in infancy (CESDI) in England, Wales, and Northern Ireland in 1994 and 1995 to deaths in two studies in the United States and one study in Australia, are seriously flawed because he has not compared like with like.¹

Direct comparisons cannot be made between these four datasets as there was no consistency in the definitions of categories of death included in the groups of births in which the deaths were compared, in the types of birth attendant, or in the content of the maternity care available. Although lessons can be learnt from the experience of other countries, conclusions should not be extrapolated from one healthcare system to another. This is why both editions of Where to be Born? focused on data collected in the United Kingdom.²

Drife did not mention any research on the subject in the United Kingdom published since 1994. Neither the National Birthday Trust Fund survey of 6044 planned home births in the United Kingdom³ nor the prospective and retrospective studies in the former Northern Region of England ^{4 5} yielded results that would alter the key conclusion of Where to be Born?, which was that "there is no evidence to support the claim that the safest policy is for all women to give birth in hospital."² Furthermore, although the confidential inquiry's data on 22 intrapartum deaths among planned home births have been cited as "proof" that home births are dangerous, the inquiry's fifth annual report (1998) drew no such conclusions.

We strongly support the view that continuing audit is needed, however. CESDI's report highlighted the lack of "denominator data" about planned and unplanned home births. Such data can be collected at national level in England, using the existing infrastructure of the maternity hospital episode statistics. We therefore urge trusts who do not currently submit complete "maternity tail" data to do so. In addition, the former Northern region of England has led the way in auditing home births at a regional level. We look forward to seeing this audit extended southwards to Yorkshire and beyond.

Alison Macfarlane, reader in perinatal and public health statistics. 
Alison.Macfarlane{at}perinat.ox.ac.uk

Rona McCandlish, research fellow. 
National Perinatal Epidemiology Unit, Institute of Health Sciences, Oxford OX3 7LF

Rona Campbell, lecturer in health services research. 
University of Bristol, Bristol BS8 2PR

Risk of home birth in Britain cannot be compared with data from other countries

EDITORDrife has asked for recent audits on the safety of home and hospital deliveries in Britain to be made available.¹ He quotes data from home births in the United States and Australia, which include cohorts of women that were not so tightly screened as a UK population would have been. Hence they include many more women at higher risk of problems. Furthermore, in these countries transport arrangements from home to hospital in case of emergency differ from those in the United Kingdom.

Drife has not referred to the National Birthday Trust survey of home births in the United Kingdom.² In this survey, a group of 3896 women booked at home and delivered at home was compared with a group of similarly low risk women who were booked at hospital and who delivered at hospital. There was one neonatal death but no stillbirths in the home delivered group, and there were two stillbirths and two neonatal deaths in the hospital booked, hospital delivered group of 3319 women. These mortality figures were small compared with the national mortality rates, for the women had been screened for home booking and so were at lower risk. The perinatal mortality rate was not considered to be a useful measure when so few babies in each group died, and so we looked at other medical problems such as postpartum haemorrhage, resuscitation of the newborn, and those factors that the women thought important to their satisfaction. We concluded that there was no evidence that women who had been screened properly in the antenatal period and planned a booked delivery for home had any higher risk than a similar group of women who delivered in hospital.

These data have been considered reliable for the United Kingdom by most people who have considered them. Drife should bear them in mind when extrapolating statements for the United Kingdom from data from other countries where the population is cared for differently. Such data allow women to choose between home and hospital delivery, for, as he says, they have the right to be provided with up to date information.

Geoffrey Chamberlain, emeritus professor. 
Department of Obstetrics, Singleton Hospital, Swansea SA2 8QA

Author's reply

EDITORWhen problems occur during a labour at home the woman is usually transferred to hospital. Chamberlain refers to one death among "3896 women booked at home and delivered at home," but his original report continued as follows: "There were two stillbirths and two neonatal deaths in the home booked/hospital delivered group (769 women). There were also three deaths (one stillbirth and two neonatal deaths) in the smaller group of women who had registered in the study but did not return their questionnaires (379 women)."¹ This makes a total of eight deaths, not one, and a rate of 1 death in approximately 600 births.

The fifth report of the confidential enquiry into stillbirths and deaths in infancy recorded 22 deaths among women booked for delivery at home.² The denominator can be calculated from the rate of home deliveries (1.84% in the previous year) and the total number of deliveries (677 759). This gives 12 471 home births and a death rate of 1 in 567. Both rates are similar to those from the United States and Australia quoted in my original letter,³ though I agree that they differ from the remarkably low figure among Young and Hey's estimated 3400 mothers.

James Drife, professor of obstetrics and gynaecology. 
University of Leeds, Leeds LS2 9NS