Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Data on babies'' safety during home births are being ignored
- Alison Macfarlane (22 October 1999)
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Audit of babies safety during home delivery
- Colin Bullough (22 October 1999)
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Home births
- Malcolm Griffiths (24 October 1999)
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Home birth in the UK can be safe
- Gavin Young (15 November 1999)
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Criticisms of Drife's analysis merit publication in the paper BMJ
- Iain Chalmers, Sheila Kitzinger (2 March 2000)
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A closer look at the studies cited by Mr. Drife
- Noemie S. Maxwell Vassilakis (24 October 2002)
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Alison Macfarlane
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It is clear that James Drife's letter does not compare like with like.1 He relates data from the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) about 873 'intrapartum-related' deaths in England, Wales and Northern Ireland in 1994 and 1995 of babies born weighing 1500 g or over2 to deaths in two studies in the United States and one in Australia.3-5 He referred to a retrospective study of 11,788 planned home births in the United States from 1987 to 1991 attended by certified nurse midwives, in which there were 23 intrapartum and neonatal deaths, including 12 due to congenital anomalies, among births to 11,081 women beginning labour with the intention of delivering at home.3 He also quoted data from a prospective study of 1404 women planning home births with certified nurse midwives in the United States from late 1994 to late 1995, in which there were three deaths among babies born to 1221 women beginning labour with the intention of delivering at home and whose labour was managed in whole or in part at home.4 In citing data based on 26 deaths associated with intrapartum asphyxia in a survey of 7002 home births in Australia, but did not mention that the authors of this study considered carefully why the mortality rates in Australia were higher than those found in studies of home birth in other countries.5 They commented explicitly that some home birth practitioners in Australia offered home birth to women who were not at low risk and that 18 of the 50 stillbirths and neonatal deaths in their study occurred in twins, post term, preterm and breech births. There was no consistency between these four datasets in the definitions of categories of death included or in the overall groups of births with which the deaths were compared. This invalidates any attempt to use these data to make direct comparisons between the outcomes of births in these settings. Furthermore, although lessons can be learned from the experience of other countries, the validity of extrapolating conclusions from one health care system to another is highly questionable.6 It is for this reason that both editions of Where to be born?focussed on data collected in the United Kingdom.7 Since the second edition appeared in 1994, a considerable amount of research has been published on the subject of place of birth, so we are surprised that James Drife did not mention it. For example, the National Birthday Trust Fund undertook a survey of 6044 planned home births in the United Kingdom8 and the former Northern Region of England published a retrospective review of perinatal loss in planned and unplanned home births from 1981 to 1994, as well as undertaking a prospective study of planned home births.9,10 None of these major studies yielded results which would alter the conclusions of Where to be born?. Nevertheless, a systematic review of research since 1994 planned, to assess whether or not there is any new evidence which would lead to modification of the conclusions. We strongly support the view that continuing audit is needed, however. Although CESDI's data about 22 intrapartum deaths among planned home births are often cited in support of the view that home births are dangerous, it is notable that its report on the subject drew no such conclusions.11 It did, however, highlight the lack of 'denominator data' about the extent to which home births are planned, however. The infrastructure already exists to collect such data on a national scale through the Maternity Hospital Episode Statistics, so we would urge trusts who do not currently submit complete 'maternity tail' data to take steps to do so. Complete data on this subject at national level would enable continuous audit of the extent to which births at home in England are planned to take place there.12 In addition, the former Northern Region 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, National Perinatal Epidemiology Unit, Institute of Health Sciences, Old Road, Oxford OX3 7LF. Rona Campbell, Lecturer in health services research, University of Bristol, Bristol BS8 2PR. Rona McCandlish, Research fellow, National Perinatal Epidemiology Unit, Institute of Health Sciences, Old Road, Oxford OX3 7LF. References 1. Drife JO. Data on babies' safety during hospital births are being compared. Letter. BMJ 1999;319:1008. 2. Confidential Enquiry into Stillbirths and Deaths in Infancy. 4th annual report for 1 January to 31 December 1995. London: Maternal and Child Health Consortium; 1997. 3. Anderson RE, Murphy PA. Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study. J Nurse Midwifery 1995; 40: 483-492. 4. Murphy PA, Fullerton J. Outcomes of intended home births in nurse- midwifery practice: a prospective descriptive study. Obstet Gynecol 1998; 92: 461-470. 5. Bastian H, Keirse MJNC, Lancaster PL. Perinatal deaths associated with planned home births in Australia: population based study. BMJ 1998; 317: 384-388. 6. Macfarlane AJ. The safest place of birth - is there a better analysis than meta-analysis? [commentary]. Birth 1997; 24 (1):14-6. 7. Chamberlain G, Wraight A, Crowley P. Home births. The report of the 1994 confidential enquiry by the National Birthday Trust Fund. New York, London: Parthenon Publishing Group, 1996. 8. Northern Region Perinatal Mortality Survey Coordinating Group. Collaborative survey of perinatal loss in planned and unplanned home births. BMJ 1996; 313: 1302-6. 9. Davies J, Hey E, Reid W, Young G for the Home Birth Study Steering Group. Prospective regional study of planned home births. BMJ 1996; 313: 1306-9. 10. Confidential Enquiry into Stillbirths and Deaths in Infancy. 5th annual report. London: Maternal and Child Health Consortium, 1998. 11. Department of Health. NHS maternity statistics, England: 1989-90 to 1994-95. Statistical Bulletin. 1997; 28:1-44. |
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Colin Bullough
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In commenting on Zander and Chamberlain's article on the 'Place of Birth' Drife quoted papers from the United States of America and Australia which reported the outcome of planned home births. He concluded that for a normal birth hospital delivery is now three to four times safer than home delivery for the baby. However he regretted the absence of a similar recent audit of home delivery in Britain. In fact such an audit was carried out in the former Northern Regional Health Authority area during 1981-94 (3). Over the whole 14 years the risk of death during delivery or in the first four weeks of life in a baby of normal birth weight and without a lethal abnormality was higher in those born to the small group of women (1%) who had booked for a home delivery compared with all other such births (1 in 538 vs 1 in 810). However, during the last 10 years of that period, when the midwife was always the community lead professional, mortality in this subgroup was lower in those booking for home delivery (1 in 1890 vs 1 in 904). The overall conclusion was that the perinatal hazard associated with planned home birth in the few women who exercised the option was low and, based on confidential enquiries, mostly unavoidable. Delays occasioned by the need to arrange and effect transfer probably contributed to only one death. These findings do not confirm those from the United States of America and Australia. However the fact that home birth in the Northern Region during this period was chosen by very few women may mean that very strict selection criteria were being adhered to. Continued audit of this kind will be particularly necessary if the number of home births rises. 1. Zander L. Chamberlain G. ABC of labour care: Place of birth. BMJ 1999:318;721-3. (13 March) 2. Drife J. Data on babies' safety during hospital births are being ignored. BMJ 199:319;1008. 3. Northern Regional Perinatal Mortality Survey Coordinating Group. Collaborative survey of perinatal loss in planned and unplanned home births. BMJ 1996:313;1306-9. Colin Bullough |
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Malcolm Griffiths, Consultant Obstetrician Luton & Dunstable Hospital
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Drife1 (9th October 1999) is critical of Zander & Chamberlain2 for stating that “no evidence exists to support the claim that a hospital is the safest place for women to have normal births”. He claims ”it is disappointing that no recent audit of the safety of home delivery in Britain is available”. He goes on to quote (selectively) from the literature, covering studies in North America (where home birth frequently takes place only in circumstances which none of us in the UK would recognise – women often choosing to risk home birth under unlicensed midwife care rather than be subjected to medicalisation an restrictions on vaginal birth after Caesarean attempts) and Australia3 referring to a study which included many inappropriate high risk cases, where the authors (and the editor of the BMJ4 in “This Week in the BMJ”) concluded only that “The death rate was higher than for comparable births nationally and much higher than home births in other countries largely due to predictably high risk births. The authors conclude that high risk home birth is inadvisable.” Drife has missed an issue of the BMJ, which was largely devoted to the issue of home births4,5,6&7. The articles in this issue demonstrated clearly that home birth was an appropriate and safe option for low risk cases. Rather than be denied an informed choice “Women should be able to choose between home birth and hospital delivery. They have a right to accurate and up to date information.”1 indeed they should be aware that in low risk cases, home birth is an appropriate option. Yours sincerely, Malcolm GRIFFITHS References: 1 Drife,J Data on babies’ safety during hospital births are note being ignored. BMJ 1999; 319: 1008 2 Zander,L Chamberlain, G ABC of labour care: Place of birth BMJ 1999; 318: 721-723 3 Bastian, H Keirse,MJNC Lancaster,PAL Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998;317:384-388 4 Editorial (23/11/96) Home births for high risk women result in high death rates. BMJ 1998;317: 5 Davies,J Hey,E Reid,W Young,G Prospective regional study of planned home births. BMJ 1996;313:1302-1306 6 Northern Region Perinatal Mortality Survey Coordinating Group Collaborative survey of perinatal loss in planned and unplanned home births. BMJ 1996;313:1306-1309 7 Ackermann-Liebrich,U Voegeli,T Gunter-Witt,K et al Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ 1996;313:1313-1318 |
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Gavin Young
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Editor - James Drife's assertion that hospital birth is three or four 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 the UK is available". Just such an audit has been running in the north of England for 18 years.[2] There has been no intrapartum death and only one neonatal (0-27 day) death in the last 15 years among the 3400 mothers (0.6%) who are estimated to have been booked for home birth when labour started. The comparable figure for all such birth in this region for these years (1984-98), after excluding lethal malformation and babies weighing less than 2.5 kg, is 1:921 (587/540830). That home birth has become statistically 'safer' than hospital birth is not, of course, unexpected since high risk mothers locally seldom press for home delivery.[3] The real question is whether mortality could have been even lower - a question that can only be addressed by confidential enquiry. National figures also exist. The comparable figure for all booked home birth in 1994-5, as established by the Confidential Enquiry into Stillbirth and Death in Infancy (CESDI), was 1:1113 births (22/24484), although it has to be remembered that the denominator for this rate includes unplanned home birth and excludes transfers in labour.[4] Nevertheless this is not very different from the rate CESDI established among all non-malformed births of > 2.5 kg in these two years (1143/1224856 or 1:1072 births). The National Birthday Trust Fund Study,[5] which did collect accurate prospective denominator data during 1994, encountered four stillbirths and one neonatal death among the 4665 mothers still booked for a home birth at 37 weeks gestation (1:933 births). We agree that women should be able to choose between home and hospital delivery. They also need accurate and balanced information to guide decision making. Unfortunately that is not what Professor Drife gave those who read his letter to the Times of May 20th, or the letter he sent you. He did not compare like with like, and 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. They would then be more likely to believe what they are told during pregnancy and, even more importantly, during labour. Gavin Young Edmund Hey for the Regional Perinatal Mortality Survey Coordinating Group, Maternity Survey Office, 25 Claremont Road, Newcastle upon Tyne NE2 4AA. References 1. Drife J. Data on babies' safety during hospital births are being ignored. BMJ 1999;319:1008. 2. Northern Region Perinatal Mortality Survey Coordinating Group. Collaborative survey of perinatal loss in planned and unplanned home births. BMJ 1996;313:1306-9. 3. Davies J, Hey E, Reid W, Young G. Prospective regional study of planned home birth. BMJ 1996;313:1302-6. 4. Confidential Enquiry into Stillbirths and Deaths in Infancy. 5th Annual Report. London: Maternal and Child Health Research Consortium, 1998:51-62. 5. Chamberlain G, Wraight A, Crowley P. Home births. Report of the 1994 confidential enquiry by the National Birthday Trust Fund. Carnforth: The Parthenon Publishing Group Inc, 1997:107-13. |
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Iain Chalmers UK Cochrane Centre and Standlake Manor, Sheila Kitzinger
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James Drife has challenged Zander’s and Chamberlain’s suggestion that no evidence exists to support the claim that a hospital is the safest place for women to have normal births, and expresses regret that there has been no recent audit of home birth in Britain. Using the BMJ’s excellent rapid response system, two obstetricians, a general practitioner and an epidemiologist pointed out promptly that Drife’s analysis failed to control for important selection biases and to acknowledge a recent audit of home birth in Britain. Six months have passed since these responses were published electronically, but this consensus about Drife’s analysis among a diverse group of respondents has not been drawn to the attention of those who read his letter in the print version of the journal. Because place of birth is an intensely political topic, about which people hold very strong views, it seems to us to be particularly important for the BMJ to correct misrepresentations of statistics published in its correspondence columns. It is not too late for the BMJ to put the record straight, and we urge the journal to do so. Iain Chalmers and Sheila Kitzinger |
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Noemie S. Maxwell Vassilakis, Librarian King County, Washington
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Mr. Drife, in his critique of the Zander and Chamberlain article, maintains that home births are three to four times riskier than hospital births and cites four articles in support of this claim. I have been able to read two of these articles in full-text and look at the abstract a third. My careful reading leads me to conclude that they do not support Mr. Drife's assertions. My first problem with Mr. Drife's argument is his use of the Bastian article to criticize the conclusions of the Zander article. A key finding of the Bastian study is that the death rate in Australian home births was higher than home births in other countries. This higher rate was "due to the inclusion of predictably high risk births and prolonged asphyxia during labour" (http://bmj.com/cgi/content/abstract/317/7155/384. These factors do not pertain to home birth in the U.K., the subject of the Zander/Chamberlain article. It is an error to support a critique of data obtained in the U.K. with data obtained in Austalia where conditions that directly affect the analyzed outcomes are demonstrably and drastically different. My other major problem with Mr. Drife's arguments is his comparison of incommensurate data. He does not explicitly trace the origin of his assertion that hospital birth is three to four times safer than home birth. However, he is probably referring to the figures found in the 1997 Confidential Enquiry into Stillbirths and Deaths in Infancy, which is the first study he cites in his letter. That figure, of 1 death in 1,561 births, refers to deaths of normal babies dying during labor at term. This group of normal babies dying at term cannot be compared with the groups reported on in the other articles he cites. Here's why: 1. Most studies of home birth safety, including Anderson's and Murphy's, look at mortality among babies born to low risk pregnancies. The Confidential Enquiry looked at births that were determined to have resulted in "normal" babies. These are different population groups; defects and illness are not always detected until after birth. 2. The figure of 1 death in 1,561 births cited in the Confidential Enquiry does not include postpartum deaths. These represent a significant portion of perinatal mortality. In 1985, for example, there was an overall perinatal mortality rate of 10.7 in the United States (http://www.cdc.gov/nchs/products/pubs/pubd/hus/tables/2001/01hus023.pdf). 5.8 of these deaths occurred within 7 days after birth. Approximately half the perinatal rate, then, was accounted for by deaths that occurred after, not during labor. The Murphy and Anderson articles look at perinatal deaths, not just deaths during labor. 3. The Confidential Enquiry study looked at births occurring in 1994 and 1995. Perinatal mortality has been significantly falling since the late 1980s and early 1990's, at least in the United States (from 10.7 in 1985 to 7.6 in 1995.) The data from the Murphy study was obtained during a roughly comparable time, however, the Anderson study looked at births occurring from 1987 through 1991. The current controversy over the safety of home birth versus the safety of hospital birth has real-life impact on women and children and, therefore, on society as a whole. It also has great economic significance, as birth is one of the costliest components of health care and, at least in the United States, home birth for low-risk pregnancies is less expensive than hospital births for low-risk pregnancies. Those who, by virtue of their positions and training, are assumed to be authoritative voices on this matter have a responsibility to be scrupulous in their characterizations of the evidence. |
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