Mortality is still important, and hospital is safer

In the 1993 United Kingdom (except Scotland) inquiry into intrapartum related mortality with a weight at birth of at least 2500 g there were 367 deaths among the 666204 babies born in hospital (1:1815) and 21 among the 10588 babies born at home (1:504). However, only nine of the 21 babies who died and were born at home were planned home births. Over this time an unknown proportion of women who planned a home delivery would have been transferred before birth on the basis of some predicted risk or emergency to hospital, where some of their babies would have died, adding to the mortality for hospital deliveries. Furthermore, a proportion of successful births at home, variously estimated at between 10% and 60% were planned to take place in hospital, but did not quite make it. In a two by two table comparing the number of babies dying who were both planned to be delivered at home and were actually delivered at home with all the other deaths (regardless of place of birth) the relative risk becomes significantly greater than 1 if at least 26% of the women who delivered at home were intending to deliver in hospital (relative risk 2.03 (95% confidence interval 1.05 to 3.92), P=0.049 by Fisher's exact test) (table 2). An analysis on the basis of originally intended place of delivery would obviously lead to a higher relative risk of death in the home intention group.

Many important obstetric skills have to be exercised at extremely short notice. Shoulder dystocia, cord prolapse, and resuscitation of an unresponsive baby would be examples requiring immediate action. Other problems give more warning, and a tendency to overdiagnose fetal compromise in a hospital setting may well lead to unnecessary caesarean sections and assisted deliveries, but at least some of these difficult interventions are likely to have been beneficial. At the same time there is room for improvement as the confidential inquiry of 1993 also suggested that optimum care, judged by hospital standards, might have rescued a further 42% of the 388 babies who died.1

The Royal College of Obstetricians and Gynaecologists recently stated that home was an accepted place to plan to have a baby but warned that it would never be possible to reproduce in the home the same standard of response and equipment that is available in hospital.2 The findings of the confidential inquiry outlined above are disturbing because they suggest that in 1993 the chances that a mother at presumed low risk would lose her baby from intrapartum causes during planned delivery at home were higher than the chances that she would lose her baby from all risks during delivery in hospital. If all national data show only four or five unexpected deaths from planned home deliveries in one year, then the chances of a randomised controlled trial detecting a difference, with current home delivery rates of 1.6%, must be infinitesimal. It would be interesting to see whether the professions, the public, and ethics committees would tolerate randomised trials if these findings are confirmed in later years. Of course mortality should not be the only outcome measure considered, but it must be one of the most important ones.